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Autumn Lake Healthcare At Berkeley Heights

35 Cottage Street, Berkeley Heights, NJ 07922 · For profit - Limited Liability company · 130 certified beds · (908) 897-1000 Medicare & Medicaid certified

Call the home — (908) 897-1000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Jul 20241 actual-harm citation$102,660 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $102,660 in federal fines (most recent 2024-07-19)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 19% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
369 Springfield Ave · (908) 665-2772 · Call to confirm hours
Pharmacy
343 Springfield Ave · (908) 464-2095 · Call to confirm hours
Grocery
404 Springfield Ave · (908) 464-8997 · Call to confirm hours
Park
125 Plainfield Ave · (908) 208-7800 · Typically dawn to dusk
Place of worship
300 Plainfield Avenue · (908) 464-1585

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.9%8.7%15.4%better
Long-stay residents who lose too much weight2.4%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.9%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%2.3%3.3%better
Long-stay residents whose ability to walk worsened0.6%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.6%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%97.2%95.3%typical
Long-stay residents with pressure ulcers5.8%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control19.5%15.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.9%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine99.5%80.1%79.4%better
Short-stay residents rehospitalized after admission27.4%24.9%22.6%worse
Short-stay residents with an outpatient ER visit6.2%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.772.071.67better
Long-stay outpatient ER visits per 1,000 resident days0.491.111.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

64.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 222 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.8%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
71.8%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 71.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 163 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF64.8%CMS range 57.0–70.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.9–12.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge71.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge58.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization4.7%CMS range 2.8–7.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.41
RN hours/ resident / day
1.00
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
0.38
RN hoursweekends
42.2%
Total nursing turnover
52.9%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 99.0 residents a day — about 76% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.37 hrs/resident/day on weekends vs 3.72 on weekdays — 9% thinner on weekends. RN hours go from 0.43 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2025-11-18)
14
at the previous standard inspection (2024-07-19)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2024-07-19 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to follow their Abuse, Neglect and Exploitation Policy and Procedure, to protect residents from physical abuse and staff by failing to ensure: a.) Resident #37 was spoken to in a harsh and abusive manner which resulted in Resident #37 crying on 07/15/24, in the presence of the surveyor and b.) Resident #50 was protected from physical abuse by Resident #74, who had a history of wandering. On 01/24/2024, Resident #74 wandered into Resident #50's room and Resident # 74 physically assaulted Resident #50 by punching them in the mouth and knocking out their front tooth. This deficient practice was identified for 2 of 3 resident's (Resident #50 and #37) reviewed for abuse, and was evidenced by the following: 1. On 07/15/24 at 12:29 PM, during the lunch meal, the surveyor observed Resident #37 in the main dining room. Resident #37 had two plates of pureed food in front of them on the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Date: 01/20/2025Complaint #: 2712991Census: 92 Based on interviews, medical record review, and review of other pertinent facility documentation on 01/21/2026 it was determined that the facility failed to follow their protocol and policy to prevent the elopement of a resident (Resident #2) who exited the facility through the lobby, got a ride to the train station, and took public transportation out of town. The resident missed the return bus and spent the night in a hospital lobby before returning to the facility the next day. This deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident 2).This deficient practice was evidenced by the following: According to the admission Record (AR) Resident #2 was admitted to the facility with diagnoses including but not limited to: other lack of coordination; schizophrenia (mental health condition that results in hallucinations, delusions, and disorganized thinking and behavior), unspecified; unspecified abnormalities of gait and mobility;…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of pertinent facility documents, it was determined that the facility failed to implement a system for staff to consistently check the function of wander guards used on residents at risk for wandering/elopement. This deficient practice was identified for 3 of 3 residents (Resident #19, #43, and #79) reviewed for wander guards. The deficient practice was evidenced by the following:1.On 9/19/25 at 10:54 AM, during an initial tour on A-wing, the surveyor observed Resident #79 lying on their bed with a beige colored band around their right ankle. The surveyor reviewed the EMR for Resident #79. A review of the admission Record reflected that Resident #79 was admitted with diagnoses which included but were not limited to; major depressive disorder, anxiety disorder, cerebral infarction (lack of blood flow to the brain causing brain tissue damage), and metabolic encephalopathy. A review of the Quarterly MDS dated [DATE] reflected that Resident #79 had a BIMS…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-18 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 25 residents reviewed (Resident #7 and Resident #93). This deficient practice was evidenced by the following: 1.On 9/19/2025 at 10:35 AM, the surveyor observed Resident #7 lying in bed with tube feeding infusing via a pump at 65 cc/hr (cubic centimeters per hour). On 9/23/2025 at 10:17 AM, the surveyor reviewed the electronic medical record (EMR) which revealed a physician order, dated 9/2/25, for continuous feeding of Glucerna 1.5 @ 65ml/hr (milliliters per hour) for a total volume of 1170 mls.A review of the individual comprehensive care plan (ICCP) included a focus area dated 9/2/25, that the resident required a tube feeding.A review of the medical provider note dated 9/2/25, includes diagnosis of diabetes (high blood sugar) and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to follow CDC pneumococcal vaccine guidelines when the facility failed to ensure one resident (Resident (R) 8) and/or his/her representative out of a sample of five reviewed for vaccinations was provided the opportunity to be vaccinated with one dose of Prevnar 20 (Pneumococcal Conjugate Vaccine (PVC) 20). This practice had the potential to increase the risk for this resident to contract pneumonia. Findings include: Review of the facility's policy titled Pneumococcal Vaccination dated 04/10/24 indicated . Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC guidelines, Pneumococcal Vaccine Timing for Adults, located at https://www.cdc.gov/pneumococcal/downloads/vaccine-timing-adults-jobaid.pdf? indicated . the minimum…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-19 · tag F0610 — failed to investigate and act on abuse reports — widespread
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 159516 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure their policy for Abuse Investigation and Icidents and Accidents was followed to ensure a thorough investigation was completed, and documented for: a.) an allegation of verbal abuse by staff to Resident #60, and b.) for a resident who was found on the floor, facing upright with a folded jacket under head, was saturated with urine, difficult to arouse and required emergent transport via 911 to the hospital (Resident #295). This deficient practice occurred for 1 of 1 resident investigated for verbal abuse (Resident #60), 1 of 3 residents investigated for unplanned hospitalization (Resident #295) and was evidenced by the following: a) On 7/14/24 at 6:28 PM, the surveyor observed Resident #60 in the hallway, the resident was alert and oriented and engaged the surveyor. On 07/16/24 11:02 AM, Reisdent #60 stated to the surveyor that there has been concerns that were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-19 · tag F0677 — failed to help fully-dependent residents with daily care — widespread
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ 00175040 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide a.) appropriate incontinence care, and personal hygiene care for 8 of 23 residents (Resident #2 and #31) unsampled residents, #9, #24, #30, #39, #50, #63, and #64, sampled on 2 of 4 resident units. The deficient practice was evidenced by the following: On 07/14/24 around 6:15 PM, the surveyor toured the North Wing of the facility. At 6:30 PM the surveyors entered the A Wing, a strong malodorous odor of urine and feces was permeated in the hallway. The surveyor observed Resident #63 sitting in a recliner chair by their door. Resident #63 could not speak, was mumbling and scratching. Resident #63 was unable to answer any question. 1. On 07/14/24 at 6:24 PM, the surveyor observed Resident #39 in bed by the door. Resident #39, stated, I need help. The surveyor observed another resident exited the room, the resident hold their nose and stated that Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-19 · tag F0684 — failed to provide proper treatment and quality of care — widespread
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint#'s NJ159619, NJ173589 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that meet each resident's physical, mental and psychosocial needs by failing to: a) ensure a procedure was in place prior to caring for a resident who required an Inotropic (intravenous medication used for heart failure) medication that required specific monitoring and b) to ensure a system was in place to provide physician ordered cardiac medications for a newly admitted resident. This deficient practice was identified for two 2 of closed records reviewed for quality of care, (Resident #296 and #297) and was evidenced by the following: Refer 755 D a) Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-19 · tag F0728 — failed to protect against nurse-aide misconduct — widespread
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure Nurse Aides (NAs) received the required training and competencies needed prior to receiving their own assignment to provide direct resident care independently. This deficient practice was identified for 2 of 2 NAs (NA #1 and NA #2) who worked on 2 of 3 Nursing units and were enrolled in a Nurse Aide Training School on 06/18/2024. The NAs failed to complete Module 2 of the NATCEP (Nurse Aide Training and Competency Evaluation Program) and there were no competencies provided by the facility to ensure training was adequate prior to receiving their own assignment. In addition, the facility had no record of the NAs having completed the required modules. The two NAs rendered direct resident care which included, but was not limited to bathing, toileting, transferring, feeding, personal, hygiene and grooming. Both NAs were enrolled in a Nurse Aide Program on 06/18/24, completed Module 1 as of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to maintain the kitchen in a clean and sanitary manner to prevent the potential spread of food borne illness by failing to ensure: a) all foods were labeled with a use by date, foods were appropriately stored, and discarded after the expiration date, b) the environment, including the main kitchen, storage areas, and kitchen equipment were maintained in a clean and sanitary manner, and c) staff washed dishes in a clean and sanitary manner. The deficient practice was evidenced by the following: On 07/14/24 at 6:13 PM, the surveyor began the kitchen tour with the Food Service Supervisor (FSS) and observed the following: -One food service staff (FS )was washing dishes using the single tank dish machine, the FS used bare hands, placed in dirty dishes, removed the clean dishes without first performing hand hygiene and placed the clean dishes in the clean area. - At that time, the surveyor then observed the FS stacking the burgundy lids on top of one another in a flat rack. The surveyor asked the FSS about the FS who…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-19 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to identify and implement interventions to address resident concerns regarding staffing issues, staff training, grievances, abuse, issues with medications incontinence care, staff competency and the use of uncertified nurse aides, through their Quality Assurance and Performance Improvement program (QAPI). This deficient practice was identified on all 4 residents care units and was evidenced by the following: Refer to: 558F, 600G, 610F, 677F, 684F, 688F, 728L On 07/14/24 during a care tour, the surveyors observed that several of the resident's were left soiled in their excrement for an extended period of time. Residents observed with 2 and 3 incontinent briefs which were soaked with urine. Residents with Fingernails long jagged and soiled. Interviews with awake and alert residents revealed that the facility was short handed, and staff were not trained properly to care for the residents. One resident who was awake and alert, told the surveyor that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · F2024-07-19 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Repeat deficiency Based on facility staff interviews and review of pertinent facility documentation on 7/17/2024, it was determined that the facility failed to provide a designated qualified Infection Prevention and Control Nurse. This deficient practice is evidenced by the following: During an interview with the facility's Infection Preventionist (IP) on 7/17/24 at 12:04 PM, she stated that she had performed both role as facility's IP and Assistant Director of Nursing (ADON) since 2019 and that she is the only IP Control Nurse in the facility at this time. The ADON further stated that she is working full time as the ADON and the IP. She stated that on November 25th, 2020, she completed her Centers for Disease Control and Prevention training, receiving her certification as a Nursing Home Infection Preventionist. During the Entrance Conference on 7/14/24 at 7:46 PM, the facility's Director of Nursing (DON) confirmed to the surveyor that the facility was licensed for 130 beds. Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-19 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to accurately assess Resident #74 for a behavior management program which would address the behavior of wandering and urinating on the floor/other residents's rooms. Resident #74 exhibited these behaviors since December 2023. The facility failed to revise the care plan to include meaningful interventions to address these behaviors. This deficient practice was observed for 1 of 3 residents reviewed for management of behaviors (Resident #74) and was evidenced by the following: On 07/15/24 at 8:30 PM, two awake and alert residents, reported that they were disturbed by Resident #74's behavior of wandering into their rooms and displacing their belongings. The wandering resident was identified as Resident #74 who resided on the back of the A Wing of the facility. A Certified Nursing Assistant (CNA ) who reported that she had a good rapport with Resident #74 confirmed the behavior and informed the surveyor that the red stop signs were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-19 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate services for a resident with limited mobility who was discharged from Physical therapy to restorative services to prevent further decline in Range of motion. This deficient practice was identified for 1 of 2 residents (Resident #13) reviewed for a limited range of motion (ROM). This deficient practice was evidenced by the following: On 07/17/24 at 09:49 AM, the surveyor observed Resident #13 seated in the hallway of the A Wing, by the Television area. Resident #13 had some black and bluish discoloration on the chin, and both hands were contracted. There were no splints or hand rolls in use at that time. The Temporary Nurse Aide (TNA) who provided care to Resident #13 confirmed that Resident #13 could not open their hands, and there were no assistive devices in the room to apply on their hands. On 07/17/24 at 10:08 AM, the surveyor inquired with the Assistant Director of Nursing (ADON), if the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident received oxygen as ordered for 1of 3 residents (Resident #243) reviewed for oxygen administration. This deficient practice was evidenced by the following: On 7/14/24 at 6:45 PM, the surveyor observed Resident #243 in bed, with the Oxygen (O2) concentrator (a medical device used for delivering oxygen) set between 2 and 2.5 liters per minute (LPM). The resident was awake and conversant. On 7/15/24 at 12:25 PM, the surveyor observed the resident in bed, with the O2 concentrator set between 2 and 3 LPM. The resident was awake and conversant. The surveyor reviewed the medical record for Resident #243. According to the admission Record, an admission summary, Resident #243 was admitted to the facility with diagnoses that included acute respiratory failure with hypoxia (low levels of O2 in body tissues, causing confusion, bluish skin, and changes in breathing and heart rate). The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the posted Nursing Home Staffing Report (24-hour staffing report) was up to date and provided accurate information. This deficient practice was evidenced by the following: On 7/14/24 at 6:05 PM, the surveyors entered the facility and observed the posted nursing home [24-hour] staffing report (NHSR) dated 7/12/24, in a plastic covered frame, on a table next to the entrance. The NHSR reflected that the current resident census (total number of residents) of 101. The posting indicated the number of registered nurses, licensed nursing staff and certified nursing staff on a shift. The shift and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care. The staffing report was not up to date and was two days late. On 7/14/24 at 7:44 PM, during the entrance conference meeting, the Director of Nursing informed the surveyor that the census was 97. On 7/15/24 at 9:13 AM, the surveyor observed the NHSR posted was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Refer 684 F Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to acquire routine medications without delay, for timely administration to Resident #245. This deficient practice was identified during the medication administration observation for one (1) of two (2) nurses, who administered medications to four (4) residents (Resident #245). The evidence was as follows: On 7/16/24 at 10:16 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #245 that included a physician's order for Cholecalciferol oral tablet 10 microgram (mcg; 400 unit), give 1 tablet one time a day for supplement, started on 6/20/24. At that time the LPN stated that she did not have the medication in stock for administration. The LPN and the surveyor proceeded to review the order audit report which revealed a pharmacy supply order was created on 6/20/24 at 8:33 PM, for Resident #245's Cholecalciferol 10 mcg (400 unit) and reflected not received. At that time, the LPN stated, it looks like it…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) provision of a permanently affixed compartment for storage of controlled dangerous substance (narcotic medications, with high potential for abuse and are tracked with detail) within the refrigerator, b.) drugs were labeled in accordance with acceptable pharmaceutical standards. This deficient practice was observed in one (1) of two (2) medication rooms, and one (1) of five (5) medication carts inspected during the medication storage and labeling task. The evidence was as follows: 1.) On 7/14/23 at 7:52 PM, during a meeting with the survey team and the Director of Nursing, the surveyor requested for the policy for Medication Storage. On 7/17/24 at 10:06 AM, in the presence of the Registered Nurse (RN), the surveyor began the refrigerator inspection located in the medication room B/Front. At that time, the RN and the surveyor observed the narcotic box was not affixed/not bolted, had a sticky white glue-like substance underneath, and was easily removed from the refrigerator. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-15 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documents it was determined that the facility failed to perform blood glucose monitoring as ordered by the physician. This was found with 3 of 5 residents , Resident #39 and Resident # 54, observed during medication pass. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: 1. On 11/1/22 at 8:34 AM the surveyor observed a Licensed Practical Nurse (LPN) obtain a blood sample from the finger of Resident # 39 for blood glucose…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to label insulin pens with expiration dates when opened. This was found in 1 of 3 medication carts inspected. The deficient practice was evidenced by the following: On 10/27/22 at 1:06 PM the surveyor inspected the B Back medication cart in the presence of the Registered Nurse (RN) who was assigned to the cart. Inside of the medication cart there were four insulin pens that were open and undated. 1) An Insulin Aspart Flexpen, 2) An Insulin Glargine Pen, and 3 and 4) 2 additional Insulin Glargine Pens for a second resident that were in the same bag and were open and undated. There was a label on the bag that contained the insulin that read Refrigerate Until Opened. The surveyor asked the RN if the insulin pens were in use. The RN said yes, except for one of the Glargine Pens in the bag but she didn't know which one was being used and which one wasn't. The RN then dated all of the pens for the day of the inspection, 10/27/22. The surveyor asked the RN how long the insulin pens were able to be used once…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to perform hand hygiene in a manner that would decrease the possibility of spreading infection. This was found with 1 of 1 wound treatments observed and with 1 of 3 Nurses during the medication pass observation. The deficient practice was evidenced by the following: 1. On 10/31/22 at 12:26 PM the surveyor observed the Unit Manager/Registered Nurse (UM/RN) perform a wound treatment to the left foot and left leg of Resident # 13. The wound treatment started at 12:26 PM and ended at 1:07 PM. The UM/RN washed her hands seven times throughtout the wound treatment of the two wounds. The length of the handwashing was as follows; 15 seconds, 10 seconds, 12 seconds, 8 seconds, 15 seconds, 15 seconds, and 18 seconds. 2. On 11/1/22 at 8:12 AM the surveyor observed LPN # 1 administer medication to 2 different residents. After administering the medication to the first resident LPN # 1 washed her hands for 12 seconds, then, after administering medication to the second resident she washed her hands for 11 seconds. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$102,660 in federal fines across 1 penalty.

  • $102,660 — penalty dated 2024-07-19

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to AUTUMN LAKE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.8+1.2 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 58 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Autumn Lake Healthcare At Crystal SpringsElkins, WV 1 of 5Autumn Lake Healthcare At Glen BurnieGlen Burnie, MD 1 of 5Autumn Lake Healthcare At HomewoodBaltimore, MD 1 of 5Autumn Lake Healthcare At Long GreenBaltimore, MD 1 of 5Autumn Lake Healthcare at GreenfieldMilwaukee, WI 1 of 5Nella's At Autumn Lake HealthcareElkins, WV 2 of 5Ashbrook Care & Rehabilitation CenterScotch Plains, NJ 2 of 5Autumn Lake Healthcare At Arlington WestBaltimore, MD 2 of 5Autumn Lake Healthcare At Ballenger CreekFrederick, MD 2 of 5Autumn Lake Healthcare At Baltimore WashingtonGlen Burnie, MD 2 of 5Autumn Lake Healthcare At BridgeparkBaltimore, MD 2 of 5Autumn Lake Healthcare At CatonsvilleCatonsville, MD 2 of 5Autumn Lake Healthcare At Glade ValleyWalkersville, MD 2 of 5Autumn Lake Healthcare At Loch RavenBaltimore, MD 2 of 5Autumn Lake Healthcare At MadisonMadison, CT 2 of 5Autumn Lake Healthcare At Memorial BridgePenns Grove, NJ 2 of 5Autumn Lake Healthcare At NorwalkNorwalk, CT 2 of 5Autumn Lake Healthcare At OverleaBaltimore, MD 2 of 5Autumn Lake Healthcare At PikesvillePikesville, MD 2 of 5Autumn Lake Healthcare At RuxtonTowson, MD 2 of 5Autumn Lake Healthcare At Salem CountySalem, NJ 2 of 5Autumn Lake Healthcare At SouthgateCarneys Point, NJ 2 of 5King David Nursing And Rehabilitation CenterBaltimore, MD 2 of 5The Subacute At Autumn Lake HealthcareVoorhees, NJ 3 of 5Autumn Lake Healthcare At Alice ManorBaltimore, MD 3 of 5Autumn Lake Healthcare At Calvert ManorRising Sun, MD 3 of 5Autumn Lake Healthcare At Chesapeake WoodsCambridge, MD 3 of 5Autumn Lake Healthcare At Chevy ChaseChevy Chase, MD 3 of 5Autumn Lake Healthcare At Patuxent RiverLaurel, MD 3 of 5Autumn Lake Healthcare At Perring ParkwayBaltimore, MD 3 of 5Autumn Lake Healthcare At RiverviewEssex, MD 3 of 5Autumn Lake Healthcare At Silver SpringSilver Spring, MD 3 of 5Autumn Lake Healthcare At Spa CreekAnnapolis, MD 3 of 5Autumn Lake Healthcare At Summit ParkCatonsville, MD 3 of 5Autumn Lake Healthcare At VinelandVineland, NJ 3 of 5Autumn Lake Healthcare At VoorheesVoorhees, NJ 3 of 5Autumn Lake Healthcare At West HartfordWest Hartford, CT 3 of 5Autumn Lake Healthcare Post-Acute Care CenterBaltimore, MD 3 of 5Autumn Lake Healthcare at BeloitBeloit, WI 3 of 5Autumn Lake Healthcare at OceanviewOcean View, NJ

Showing 40 of 58; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
GLUCK, RIVKAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF10%since 06/01/2017
HANDLER, SAMUELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 06/01/2017
MJH GROUP LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2017
BH ASSOCIATES REALTY LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 06/01/2017
SCHWARTZ, MARKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/07/2016
SITZER, SHIMONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
JACOBOWITZ, JACOBIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/18/2025
SCHWARTZ, JOELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/18/2025
MEISELS, MORRISIndividualADP OF THE SNFsince 06/01/2017
STERN, ARYEHIndividualADP OF THE SNFsince 06/01/2017

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.7M
Net patient revenuemost recent cost report
-10.0%
Operating marginrevenue minus expenses
$2.5M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 12%Other / private 29%

This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$398per resident / day
operating cost
$12,099per month
≈ monthly operating cost
$362per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315195. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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